Congressional Republican proposals to "repeal and replace" Obamacare would slash Medicaid, the nation's health insurance program for the poor. In so doing, they would devastate Los Angeles in ways that may not yet be fully appreciated. One in 20 of the nation's Medicaid recipients lives in L.A. County and relies on the program for their healthcare. About 4 million strong, they make up about 40% of the county's population. Many would be at grave risk of losing their health coverage, and consequently all but emergency medical treatment, under the Republicans' program. Current programs to provide housing and treatment to thousands of people living on the streets, or heading there after their discharge from hospitals or release from jails and prisons, would be seriously curtailed.

Senate GOP leaders put their version of the repeal-and-replace bill on hold Tuesday after several Republicans balked at the planned vote this week. But the efforts to drum up support for the measure will continue, and a vote could happen after lawmakers return from their 4th of July recess.

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Los Angeles County has more people on Medicaid than 45 states do. It has about as many people on Medicaid as the entire population of Kentucky, Senate Majority Leader Mitch McConnell's home state.

Why are so many L.A. residents on Medi-Cal (California's name for its Medicaid programs)? Two primary reasons.

First, despite its pockets of fabulous wealth, the region is also beset with intense poverty. The poor never had it easy, but at least in the past they had a fighting chance to make ends meet in Los Angeles, where manufacturing and low-skill jobs were plentiful and the cost of living — rent, food, transportation — was relatively low. But now far fewer jobs pay enough to meet the skyrocketing cost of getting by. Millions of people who once could save up enough money for annual medical check-ups for every member of the family, plus the occasional doctor visit to deal with broken bones or serious illness, now need assistance to stay healthy and, by the way, to keep sickness sufficiently under control so that it does not turn into an epidemic and does not sap the workforce, poorly paid though much of it may be.

And second, one of the most valuable components of Obamacare was Medicaid expansion, under which far more people became eligible to participate in the program in states, like California, that opted in. That includes an additional 1.2 million adults in Los Angeles County who earned less than $15,400 annually.

So while the large number of L.A. Medi-Cal recipients was never a sign of economic good health, the expansion was a very good development. It helped the county finally take care of its poor by keeping more of them healthy, working, going to school and caring for their families — and shifting routine care out of costly emergency rooms.

Medi-Cal is managed care, and as such it's a much better approach to cost control than having uninsured people show up in ERs. The only other way to bring the growing costs of the industry under control would be to bring everyone into the insurance tent. Otherwise, it will be difficult to change the incentives that are driving healthcare costs ever skyward.

If the Senate bill or similar deep cuts to Medicaid are adopted, more than a million adults will ultimately lose the coverage they currently enjoy under the expansion. In addition, the county estimates that about 323,000 adults will lose the subsidies that currently enable them to afford coverage from private insurers.

Innovative L.A. County programs like Housing for Health, which leverages Medi-Cal dollars to fund shelter for people whose mental health or substance treatment requires the security of a roof, a door and a key as much as medicine and other therapy, would be crippled. County officials would have to decide whether to reduce the housing and services, or else raid other programs for funding. But there are few programs to raid, because most are non-discretionary. The Board of Supervisors has no choice but to fund them.

The effort to combat homelessness would continue because of the funding for housing that city voters approved with Measure HHH and for services in the county's Measure H. But the impact of that money would be far less with no Medi-Cal funding to leverage.

Efforts to move people away from emergency rooms to primary medical treatment would likely evaporate. So would the disposable income of people currently covered under expanded Medi-Cal who, for now, do not have to choose between a doctor visit and a trip to the grocery store. So would thousands of healthcare jobs.

Didn't L.A. County cover all these people before Obamacare? It tried — and we see the results today on our streets.

With expanded Medicaid, there was finally a mappable route to viability and perhaps admission to the ranks of the middle class for Los Angeles County's poor, sick, mentally ill, addicted and others living on the margins — and a route to a higher quality of life for the rest of us, who are at times overwhelmed by the misery we see on our streets and at times angry that the government that we elect and fund has done so little about it. Without it — and with the Republican prescription for healthcare, homelessness and public safety — we can expect our poor neighbors to become poorer. And more numerous.